Invoice Surgeon in Bangladesh Dhaka –Free Word Template Download with AI
Senior Consultant Surgeon
Apex Surgical Center & Diagnostic Complex
House #12, Road #5, Dhanmondi R/A
Dhaka-1205, Bangladesh
Email: [email protected] | Phone: +880 1711-XXXXXX
Invoice No: INV-2023-10-045
Date: October 24, 2023
Due Date: November 07, 2023
Bill To:
Patient Name: Mr. Kamal Hossain
Address: Flat #304, Green View Apartment, Mirpur-10, Dhaka, Bangladesh
Phone: +880 1812-XXXXXX
NID No: 1234567890123
Insurance Provider: Jubilee Life Insurance (Policy #JL-998877)
| # | Description of Services | Quantity | Unit Price (BDT) | Total (BDT) |
|---|---|---|---|---|
| 1 | Consultation and Pre-operative Assessment by Senior Surgeon | 1 | 2,500.00 | 2,500.00 |
| 2 | Surgical Fee: Laparoscopic Cholecystectomy (Complex Case) | 1 | 45,000.00 | 45,000.00 |
| 3 | Assisting Surgeon Fee | 1 | 10,000.00 | 10,000.00 |
| 4 | Anesthesia Services (General Anesthesia with Monitoring) | 1 | 15,000.00 | 15,000.00 |
| 5 | Operating Room Charges (4 Hours) | 4 | 5,000.00 | 20,000.00 |
| 6 | Disposable Surgical Instruments and Laparoscopic Trocars | 1 | 12,000.00 | 12,000.00 |
| 7 | Post-operative Ward Stay (ICU - 24 Hours) | 1 | 18,000.00 | 18,000.00 |
| 8 | Post-operative Ward Stay (General Ward - 2 Days) | 2 | 4,500.00 | 9,000.00 |
| 9 | Post-operative Medications and Dressing Materials | 1 | 3,500.00 | 3,500.00 |
| 10 | Follow-up Consultation (Within 7 Days) | 1 | 1,500.00 | 1,500.00 |
Terms and Conditions:
1. Payment is due within 14 days of the invoice date. Late payments may incur a penalty of 2% per month.
2. This invoice covers all surgical and hospital charges related to the procedure performed at United Hospital, Dhaka.
3. Insurance claims have been processed directly with Jubilee Life Insurance. The remaining balance is payable by the patient.
4. Please quote the Invoice Number (INV-2023-10-045) in all communications regarding this payment.
5. For any discrepancies, please contact our billing department within 7 days.
Payment Methods:
Bank Transfer:
Bank Name: Dutch-Bangla Bank Ltd.
Account Name: Apex Surgical Center
Account Number: 0123456789012
Branch: Dhanmondi, Dhaka
Cash/Card: Payments can be made at the hospital billing counter or via credit/debit card at the clinic.
Authorized by:
Dr. Rahim AhmedSenior Consultant Surgeon
Apex Surgical Center
Patient Acknowledgment:
Mr. Kamal HossainPatient / Authorized Representative ⬇️ Download as DOCX Edit online as DOCX
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